Supraglottic airway: Difference between revisions
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==Indications== | ==Indications== | ||
*Need for positive pressure ventilation (PPV) | *Need for positive pressure ventilation (PPV) | ||
** | **Primary or rescue airway<ref name="Anesthesia">Apfelbaum JL, et al.; American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013 Feb;118(2):251-70</ref> | ||
** | **Conduit/guide for elective or rescue fiberoptic intubation<ref name="NAP4">Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Cook TM, Woodall N, Frerk C; Fourth National Audit Project. Br J Anaesth. 2011 May;106(5)</ref> | ||
**Intubating LMA may be used to guide placement of an endotracheal tube | |||
*Field intubation by paramedics, especially in pediatric patients<ref>Zhu X-Y, Lin B-C, Zhang Q-S, Ye H-M, Yu R-J. A prospective evaluation of the efficacy of the laryngeal mask airway during neonatal resuscitation. Resuscitation. 2011;82(11):1405–1409. doi:10.1016/j.resuscitation.2011.06.010</ref><ref>Calkins MD, Robinson TD. Combat trauma airway management: endotracheal intubation versus laryngeal mask airway versus combitube use by Navy SEAL and Reconnaissance combat corpsmen. J Trauma. 1999;46(5):927–932</ref> | |||
==Contraindications== | ==Contraindications== | ||
* | ===Absolute=== | ||
*Spontaneous respirations | |||
*Gag reflex | |||
===Relative=== | |||
*Significant facial trauma | |||
===Difficult Supraglottic Device (RODS)=== | |||
*'''R'''estricted mouth opening | |||
*'''O'''bstruction | |||
*'''D'''istorted airway | |||
*'''S'''tiff lungs (chronic pulmonary disease, obesity) or neck (C-spine collar, limited neck extension) | |||
==Equipment Needed== | ==Equipment Needed== | ||
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*Appropriate sedation/paralytic agents, if indicated | *Appropriate sedation/paralytic agents, if indicated | ||
===[[LMA]] Sizes<ref>Tarascon Adult Emergency Pocketbook</ref>=== | |||
{{LMA sizes}} | {{LMA sizes}} | ||
===iGel Sizes=== | |||
{{igel sizes}} | {{igel sizes}} | ||
Line 18: | Line 31: | ||
''Due to variety of devices and placement techniques, impossible to give exact universal procedure'' | ''Due to variety of devices and placement techniques, impossible to give exact universal procedure'' | ||
#Prepare patient as for intubation | |||
#If patient is awake, provide topical anesthetic | |||
#Place supraglottic airway device by one of the following techniques: | |||
#*Use thumb or index finger to guide device along midline of hard palate with cuff deflated or partially inflated and advance until seated | |||
#*Insert device with cuff facing hard palate, then rotate 180 degrees while advancing (similar to [[OPA]] insertion) | |||
#*Insert laterally 45 degrees against tongue, advance and rotate to midline | |||
#Inflate cuff (if applicable) | |||
#Confirm placement as with endotracheal tube | |||
===Intubating LMA<ref>https://calsprogram.org/manual/volume2/Section5_AirwaySkills/09-AirSk8IntubLarynMaskAirway13.html</ref>=== | |||
#Prepare patient as for intubation | |||
#Partially deflate the cuff of the iLMA and lubricate | |||
#Holding iLMA by metal handle only, insert into patient's mouth with the posterior surface of the iLMA against the hard palate | |||
#Advance the iLMA until it is seated | |||
#Inflate the iLMA cuff | |||
#Ventilate patient and confirm placement as usual | |||
#Lubricate endotracheal tube | |||
#Insert ETT into the aperture on the iLMA | |||
#Slide ETT to appropriate depth | |||
#Inflate ETT cuff and confirm placement as usual | |||
#Disconnect adaptor from ETT | |||
#Deflate iLMA cuff | |||
#Use obturator to push against ETT while slowly removing iLMA | |||
#Grasp ETT in the oral cavity as soon as able | |||
#When iLMA is fully removed, reattach ETT adaptor | |||
#Ventilate patient and confirm placement as usual | |||
==Complications<ref name="Anesthesia" />== | ==Complications<ref name="Anesthesia" />== | ||
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*Oropharyngeal leak pressure = the applied pressure at which the seal between the device and the larynx begins to leak. | *Oropharyngeal leak pressure = the applied pressure at which the seal between the device and the larynx begins to leak. | ||
**Peak inspiratory pressure needs to be less than the oropharyngeal leak pressure for effective ventilation and to prevent gastric insufflation.<ref name="LMA">Patel B., Bingham R. Laryngeal mask airway and other supraglottic airway devices in paediatric practice. Contin Educ Anaesth Crit Care Pain (2009) 9 (1): 6-9.</ref> | **Peak inspiratory pressure needs to be less than the oropharyngeal leak pressure for effective ventilation and to prevent gastric insufflation.<ref name="LMA">Patel B., Bingham R. Laryngeal mask airway and other supraglottic airway devices in paediatric practice. Contin Educ Anaesth Crit Care Pain (2009) 9 (1): 6-9.</ref> | ||
*Higher failure rate with obese patients, inappropriate | *Higher failure rate with obese patients, inappropriate patient position (e.g. trendelenberg), and placement by inexperienced provider<ref name="NAP4" /> | ||
==See Also== | ==See Also== | ||
===Airway Pages=== | |||
*Pre-intubation | |||
**[[Predicting the difficult airway]] | |||
**[[Bag valve mask ventilation]] | |||
**[[Apneic oxygenation]] | |||
***[[EBQ:ED Preoxygenation]] | |||
*Induction | |||
**[[Critical care quick reference]] | |||
**[[Rapid sequence intubation]] | |||
**[[Delayed sequence intubation]] | |||
*[[Intubation]] | *[[Intubation]] | ||
*[[Advanced | **[[Intubation (peds)]] | ||
*[[ | **[[Direct laryngoscopy]] | ||
**[[Video Laryngoscopy]] | |||
**[[Bougie]] | |||
**[[The difficult airway]] | |||
**[[Advanced airway adjuncts]] | |||
***[[Supraglottic airway]] | |||
**Non-traditional intubation | |||
***[[Awake intubation]] | |||
***[[Nasal intubation]] | |||
***[[Blind Digital Intubation]] | |||
*[[Surgical airways]] | |||
**[[Surgical cricothyrotomy]] | |||
**[[Needle cricothyrotomy]] | |||
**[[Pediatric jet ventilation]] | |||
*Post-intubation | |||
**[[Mechanical ventilation (main)]] | |||
**[[Deterioration after intubation]] (DOPE) | |||
==External Links== | |||
*[https://www.merckmanuals.com/professional/critical-care-medicine/how-to-do-other-airway-procedures/how-to-insert-a-laryngeal-mask-airway?query=supraglottic%20airway Merk Manual - How To Insert a Laryngeal Mask Airway] | |||
*[https://www.merckmanuals.com/professional/critical-care-medicine/how-to-do-other-airway-procedures/how-to-insert-an-esophageal-tracheal-double-lumen-tube-combitube-or-a-king-laryngeal-tube?query=supraglottic%20airway Merk Manual - How To Insert an Esophageal-Tracheal Double Lumen Tube (Combitube®) or a King Laryngeal Tube] | |||
===Videos=== | |||
*Laryngeal Mask Airway (https://www.youtube.com/watch?v=-oXa-f5qkGY) | |||
*I-Gel (https://www.youtube.com/watch?v=YuG6k6ndBpM) | |||
*King Airway (https://www.youtube.com/watch?v=yJGuxDny_fo) | |||
==References== | ==References== |
Latest revision as of 13:39, 17 July 2021
Indications
- Need for positive pressure ventilation (PPV)
- Field intubation by paramedics, especially in pediatric patients[3][4]
Contraindications
Absolute
- Spontaneous respirations
- Gag reflex
Relative
- Significant facial trauma
Difficult Supraglottic Device (RODS)
- Restricted mouth opening
- Obstruction
- Distorted airway
- Stiff lungs (chronic pulmonary disease, obesity) or neck (C-spine collar, limited neck extension)
Equipment Needed
- Supraglottic Airway (SGA) device (many options exist, see below)
- Appropriate sedation/paralytic agents, if indicated
LMA Sizes[5]
Mask Size | Weight (kg) | Age (yr) | LMA Length (cm) | LMA Cuff Vol (mL) | Largest ETT^ (mm) |
1 | <5 | <0.5 | 10 | 4 | 3.5 |
1.5 | 5-10 | <1 | 10 | 5-7 | 4 |
2 | 6.5-20 | 1-5 | 11.5 | 7-10 | 4.5 |
2.5 | 20-30 | 5-10 | 12.5 | 14 | 5 |
3 | 30-60 | 10-15 | 19 | 15-20 | 6 |
4 | 60-80 | >15 | 19 | 25-30 | 6.5 |
5 | >80 | >15 | 19 | 30-40 | 7 |
^Largest ETT that can pass thorough "Intubating LMA" (ILMA)
iGel Sizes
igel size | patient size | weight (kg) |
1 | neonate | 2-5 |
1.5 | infant | 5-12 |
2 | smal pediatric | 10-25 |
2.5 | large pediatric | 25-35 |
3 | small adult | 30-60 |
4 | medium adult | 50-90 |
5 | large adult | 90+ |
Procedure
Due to variety of devices and placement techniques, impossible to give exact universal procedure
- Prepare patient as for intubation
- If patient is awake, provide topical anesthetic
- Place supraglottic airway device by one of the following techniques:
- Use thumb or index finger to guide device along midline of hard palate with cuff deflated or partially inflated and advance until seated
- Insert device with cuff facing hard palate, then rotate 180 degrees while advancing (similar to OPA insertion)
- Insert laterally 45 degrees against tongue, advance and rotate to midline
- Inflate cuff (if applicable)
- Confirm placement as with endotracheal tube
Intubating LMA[6]
- Prepare patient as for intubation
- Partially deflate the cuff of the iLMA and lubricate
- Holding iLMA by metal handle only, insert into patient's mouth with the posterior surface of the iLMA against the hard palate
- Advance the iLMA until it is seated
- Inflate the iLMA cuff
- Ventilate patient and confirm placement as usual
- Lubricate endotracheal tube
- Insert ETT into the aperture on the iLMA
- Slide ETT to appropriate depth
- Inflate ETT cuff and confirm placement as usual
- Disconnect adaptor from ETT
- Deflate iLMA cuff
- Use obturator to push against ETT while slowly removing iLMA
- Grasp ETT in the oral cavity as soon as able
- When iLMA is fully removed, reattach ETT adaptor
- Ventilate patient and confirm placement as usual
Complications[1]
- Bronchospasm
- Hoarseness
- Laryngeal nerve injury
- Hypoglossal nerve injury
- Pharyngeal edema
- Dysphagia
Special Considerations
- There are 2 generations of supraglottic airway devices[7][2]
- 1st Gen = classic LMA, other standard LMAs
- 2nd Gen = iGel, LMA Supreme, Pro-Seal LMA (PLMA)
- Second generation devices achieve improved esophageal and pharyngeal seal (causes ↑ oropharyngeal leak pressure), incorporate a "drain tube" that allows access to the esophagus and stomach, and usually have an incorporated bite block.
- Oropharyngeal leak pressure = the applied pressure at which the seal between the device and the larynx begins to leak.
- Peak inspiratory pressure needs to be less than the oropharyngeal leak pressure for effective ventilation and to prevent gastric insufflation.[8]
- Higher failure rate with obese patients, inappropriate patient position (e.g. trendelenberg), and placement by inexperienced provider[2]
See Also
Airway Pages
- Pre-intubation
- Induction
- Intubation
- Surgical airways
- Post-intubation
External Links
- Merk Manual - How To Insert a Laryngeal Mask Airway
- Merk Manual - How To Insert an Esophageal-Tracheal Double Lumen Tube (Combitube®) or a King Laryngeal Tube
Videos
- Laryngeal Mask Airway (https://www.youtube.com/watch?v=-oXa-f5qkGY)
- I-Gel (https://www.youtube.com/watch?v=YuG6k6ndBpM)
- King Airway (https://www.youtube.com/watch?v=yJGuxDny_fo)
References
- ↑ 1.0 1.1 Apfelbaum JL, et al.; American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013 Feb;118(2):251-70
- ↑ 2.0 2.1 2.2 Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Cook TM, Woodall N, Frerk C; Fourth National Audit Project. Br J Anaesth. 2011 May;106(5)
- ↑ Zhu X-Y, Lin B-C, Zhang Q-S, Ye H-M, Yu R-J. A prospective evaluation of the efficacy of the laryngeal mask airway during neonatal resuscitation. Resuscitation. 2011;82(11):1405–1409. doi:10.1016/j.resuscitation.2011.06.010
- ↑ Calkins MD, Robinson TD. Combat trauma airway management: endotracheal intubation versus laryngeal mask airway versus combitube use by Navy SEAL and Reconnaissance combat corpsmen. J Trauma. 1999;46(5):927–932
- ↑ Tarascon Adult Emergency Pocketbook
- ↑ https://calsprogram.org/manual/volume2/Section5_AirwaySkills/09-AirSk8IntubLarynMaskAirway13.html
- ↑ Timmermann, A. Supraglottic airways in difficult airway management: successes, failures, use and misuse. Anaesthesia, 2011, 66(Suppl. 2), pages 45–56.
- ↑ Patel B., Bingham R. Laryngeal mask airway and other supraglottic airway devices in paediatric practice. Contin Educ Anaesth Crit Care Pain (2009) 9 (1): 6-9.